Breast cancer


Breast cancer is the commonest form of cancer in females. 99% of cases occur
in women, but men can also develop breast cancer (see sex and illness).

Breast cancer can be detected by a woman when washing, by her partner during
foreplay, by formal breast self-examination or by screening mammography.
Only mammography has been shown to reduce mortality from breast cancer.

On finding a lump, the next step should be to visit the family doctor. The
usual investigations should include an examination and mammogram. An
ultrasound and biopsy may also be undertaken. If there is suspicion or
confirmation of problems at this stage, the patient will be seen by a
surgeon. Many large centres have 'breast' surgeons, and even in centres with
2-3 surgeons it is probably better to see the one with an interest in breast
cancer.

If breast cancer is confirmed by biopsy or by open excision, the diagnosis
has been established. The second phase is then tumour staging which deals
with questions of how big, how much and how far.

The breast lump must be excised either as a local operation called
lumpectomy or as a larger operation called mastectomy. In either case the
surgeon must establish that the cancer has been completely excised (clear
margins) by the operation. If the lumpectomy operation does not have clear
margins, then the operation should be repeated until clear.

The lymph nodes in the axilla also need to be studied. In the past, large
axillary operations took out 10-40 nodes to establish whether cancer had
spread. More recently sentinel biopsy has become popular as it has far fewer
side effects.

In some cases at high risk, CT scans, chest X-rays and blood tests will also
be advisable to look for any metastasis or secondary cancer that has spread
a long way from the site of the primary tumour.

Oncologists then assign a TNM code as a shorthand categorisation which in
turn determines treatment recommendations. SOme biological features of the
cancer such as estrogen receptor and HER2-neu oncogene are also determined
as they also affect treatment recommendations.

At present, the treatment recommendations follow this pattern:

  1. after a lumpectomy, the high local recurrence risk (~40%) is reduced by
     radiotherapy to the breast
  2. if the lymph nodes are positive, the high mortality risk (30-80%) is
     reduced by systemic treatment (which could be either hormones or
     chemotherapy).
  3. in young patients, the most useful systemic therapy is chemotherapy
     (usually regimens such as CMF, AC and/or taxol)
  4. in old patients, the most useful systemic therapy is hormone therapy
     (tamoxifen)
  5. in old patients, chemotherapy has increasing side effects as the
     patients passes 65
  6. in patients with estrogen receptor negative tumours, the most useful
     systemic therapy is chemotherapy
  7. in patients with estrogen receptor positive tumours, the most useful
     systemic therapy is hormone therapy

For some early tumours, systemic treatments may not be recommended. After
mastectomy, radiotherapy may not be recommended. For advanced tumours, there
is an established role for all three modalities of treatment (surgery,
radiation, systemic therapy) as the combination produces the best results.

A gene, BRCA1, has been linked to the familial form of breast cancer. Women
in families expressing this gene have a much higher risk of developing
breast cancer than the average woman.

Several things have been statistically linked to an increased risk of having
breast cancer. The greatest risk by far is being female - females are about
100 times more likely than males to get breast cancer. Other established
risk factors include having the first child late, having no children, not
breastfeeding, having early menarche and late menopause, taking the
contraceptive pill and taking hormone therapy.

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